2013 consumer report card on health insurance carriers in connecticut

Consumer Report Card on Health Insurance

Carriers in Connecticut

October 2013

Table of Contents

About this Report Card 1 Dear Health Insurance Customer: Managed Care Plan Comparison Worksheet 2

Choosing the right health insurance coverage for you and your family can Health Benefit Plan Statutes 3 be difficult and confusing. Therefore, the Connecticut Insurance Department MCOs included in the Report Card 4 (CID) is pleased to provide you with the latest edition of your Consumer Report MCOs included in the Report Card and their Websites 5 Card. This Report Card is designed to help you compare Health Maintenance General Information Organizations – commonly referred to as HMOs – and the 15 insurers with the HMOs 6 highest premium volume in Connecticut, that offer Managed Care Plans. It will Indemnity Carriers 8 help you compare overall customer satisfaction and review benefit usage Participating Providers by County amongst the Managed Care Organizations in Connecticut. HMOs 10

The CID is a state agency that is statutorily required to regulate the insur Indemnity Carriers 13 ance industry. As regulators, our only interest is to provide you with the most Measures of Members Usage of Benefits accurate and unbiased information available. In an effort to help focus your HMOs 16 decision-making, we have included a Worksheet that lists the criteria that the Indemnity Carriers 23 Department believes are most critical in determining which health plan is right Utilization Review Data for you. I urge you to work with your insurer or independent agent to help pick HMOs 30 the plan that is most appropriate for the needs of you and your family. Indemnity Carriers 31

Connecticut residents are fortunate to have many health insurance Behavioral Health Comparisons options. Therefore, you will find that companies offer various benefits at dif HMOs 32 ferent prices based on a variety of factors. It is my hope that you will take a few Indemnity Carriers 37 minutes to consider the information contained in this Report Card and to com Member Satisfaction Survey Results plete the Worksheet. Doing so may make the difference in helping you to HMOs 42 choose the right company for you and your family. Indemnity Carriers 44

Medical Loss Ratios by Carrier 48 Sincerely, Glossary 49

Other Indemnity MCOs not Included in This Report 52 Where to Find Help or Additional Information cover

Thomas B. Leonardi Insurance Commissioner

1

About This Report Card The information in this report card is based on data provided by the MCOs as of year end 2012. This report card does not contain information on specific plans offered by the MCOs. Each MCO offers several different plans, and often tailors them to a specific policyholder’s needs. You will need to get additional information from the MCO or your employer to make your choice. In addition to this report card, you will need provider directories, premium or contribution rates and schedules of benefits for each plan you are considering.

Q. What types of plans are covered in this comparison? A. Managed Care Plans offered by HMOs or traditional indemnity companies. These plans attempt to manage the access, cost and quality of health care by pro

moting early detection and preventive care under the supervision of a primary care physician (PCP) who participates in the managed care plan’s network.

Q. How does the Department get its information for this Report Card? A. The Department sends a series of surveys to the companies. Their answers to our questions are summarized and included in this Report Card.

Q. Who can I call if I have questions about the information contained in this Report Card? A. The Insurance Department’s Consumer Affairs Division at 1-800-203-3447.

Q. Does this Report Card evaluate all benefit options? A. No. Because different plans provide different benefits, it would be nearly impossible to do so. Also, many benefits are mandated by law and therefore would

be the same across plans.

Q. Who can I call if I have questions about specific benefit options? A. Your employer, your insurer, or your independent agent.

Q. Does this Report Card include information regarding Medicare, Medicaid and other entitlement programs? A. No.

Consider the following factors when evaluating your options:

• Does the participating network include your current physicians, hospitals, or pharmacies? • Are the plan’s participating providers convenient in location to your home or office? • Does the plan include an option for seeing a provider outside of the plan’s network? • Does the plan provide the health services that you are most likely to need? • What copayments, coinsurance, or deductibles will you be responsible for paying? • What is the premium or employee contribution?

2

Managed Care Plan Comparison Worksheet In addition to this report card, you will need provider directories, premium or contribution rates and schedules of benefits for each plan you are considering.

Option 1 Option 2 Option 3 Option 4 Option 5 MCO Name

Plan’s network includes my current physician

Plan’s network includes the hospital that I prefer

Plan is a “gatekeeper” plan

Physician Office Visit Copayment

Specialist Physician Office Visit Copayment

Emergency Care Copayment

Urgent Care Copayment

Inpatient Per Confinement Copayment

Outpatient Surgical Facility Copayment

Family Planning Coverage Included

Prescription Drug Coverage Included

Brand Name/Generic Copayment

Hospice Care Coverage Included

Physical Therapy Coverage Included

Level of Durable Medical Equipment Included

Routine Eye Exam Coverage Included

Routine Hearing Exam Coverage Included

Organ and Tissue Transplant Coverage Included

Benefit features meet my needs (Review Plan Benefits)

If Out of Network Coverage Included

Deductible – Individual/Family

Coinsurance

Lifetime Maximum Benefit

The worksheet does not include mandated benefits, since they must be included in all managed care plans issued in Connecticut.

3

Health Benefit Plan Statutes INDIVIDUAL GROUP INDIVIDUAL GROUP

SUBJECT STATUTE STATUTE SUBJECT STATUTE STATUTE

Pre-authorized benefits paid unless 38a-472g 38a-472g Bone Marrow Testing 38a-492o 38a-518o 3 days prior notification to adm/serv/proc Home Health Care 38a-493 38a-520 Pre-Existing Condition Waiver 38a-476 38a-476 Definition Of dependent child to 26 38a-497 38a-512b Post-claims underwriting 38a-477b 38a-477b Ambulance Service 38a-498 38a-525 Applications must include state and federal MLR 38a-477c 38a-477c Extend isolation & emergency 38a-498b 38a-525b Medical necessity 38a-482a 38a-513c services to mobile field hospitals Regulating limited benefit medical plans 38a-482b 38a-513d Health Care Services to Residents 38a-498c 38a-525c No Lifetime max. on "essential benefits"/ 38a-482c 38a-512c with Elevated Blood Alcohol Levels defined lifetime on non-essential benefits Mammography/Breast Cancer Screening 38a-503 38a-530 Experimental Treatments 38a-483c 38a-513b Maternity Care & Postpartum Care (48/96 hrs) 38a-503c 38a-530c Benefits for Mental Illness 38a-488a 38a-514 Mastectomy or Lymph Node Dissection (48 hrs) 38a-503d 38a-530d Therapies for treatment of autism spectrum 38a-488b 38a-514b Prescription Birth Control 38a-503e 38a-530e Continuation for Mentally or Physically 38a-489 38a-515 Preventive Pediatric Care 38a-535 Handicapped Children Blood screening added to preventive pediatric 38a-490d 38a-535(b) Newborn Infants 38a-490 38a-516 Notice of Cancellation of Group Coverage 38a-537 Birth-To-Three Program (Early 38a-490a 38a-516a Policy to Allow Spouse Coverage as Both 38a-541 Intervention Services) Dependent and Employee Hearing Aids for Children 12 and Younger 38a-490b 38a-516b Tumors and Leukemia/Breast Implant 38a-504 38a-542 Craniofacial Disorders 38a-490c 38a-516c Removal & Reconstruction, oral chemotherapy Coverage for In-patient Dental 38a-491a 38a-517a Cancer Clinical Trials 38a-504a-g 38a-542a-g Accidental Ingestion of a Controlled Drug 38a-492 38a-518 OON facility during treatment in a clincal trials 38a-504d 38a-542d Coverage for Hypodermic Needles and Syringes 38a-492a 38a-518a Age Discrimination-Small Group less than 20 Employees 38a-543 Cancer Drugs Not to be Excluded 38a-492b 38a-518b Continuation of Coverage 38a-546 Coverage for Prescription Foods/Formula 38a-492c 38a-518c Coverage for Prospective Adoptive Children 38a-508 38a-549 Coverage for Diabetes 38a-492d 38a-518d Infertility Treatment & Procedures 38a-509 38a-536 Diabetes Outpatient Self-Management Training 38a-492e 38a-518e Prescription Drug- mail order prohibition 38a-510 38a-544 Screening for Prostate Cancer 38a-492g 38a-518g Access to Imaging Services 38a-511 38a-550 Lyme Disease Treatment 38a-492h 38a-518h Continuation, Extension & Conversion Rights 38a-512a Pain Management 38a-492i 38a-518i Group specified disease benefit 38a-513d Ostomy Appliances and Supplies 38a-492j 38a-518j Colorectal Cancer Screening 38a-492k 38a-518k NNeeww PPuubblliicc AAccttss ffoorr 22001133 Developmental Needs of Children & Youth 38a-492l 38a-516d Revisions to UR/Mental Health & Substance abuse(gun bill) PA13-3 PA13-3 with Cancer Revisions to Autism Spectrum disorders PA13-84s.1 PA13-84s.2 Requiring coverage for wound care 38a-492n 38a-518m Synchronizing prescription refills for chronic illness PA13-131s.1 PA13-131s.2 for individuals with epidermolysis bullosa Copayments for physical therapy PA13-307s.1 PA13-307s.2

This listing is not an offical itemization of all applicable laws and regulations. Although attempts have been made to ensure that this list is all inclusive, the Department does not take any responsibility for any decisions that are made on the basis of a potential oversight on its behalf. If you have a specific area that is of interest, you are strongly encouraged to fully research that issue or contact the Department.

4

Managed Care Organizations Included in this Report Card

Health Maintenance Organizations Aetna Health Aetna Health, Inc. of CT Anthem BC-BS Anthem Blue Cross & Blue Shield of CT, Inc. CIGNA CIGNA HealthCare of CT, Inc. ConnectiCare ConnectiCare, Inc. Oxford Oxford Health Plans (CT), Inc.

Indemnity Managed Care Organizations Aetna Life Aetna Life Insurance Co. Anthem BC-BS Anthem Blue Cross & Blue Shield of CT, Inc. Celtic Celtic Insurance Co. CIGNA H&L Cigna Health and Life Insurance Co. ConnectiCare ConnectiCare Insurance Co., Inc. CT General Connecticut General Life Insurance Co. Golden Rule Golden Rule Insurance Co. John Alden John Alden Life Insurance Co. Oxford Health Oxford Health Insurance Co. Time Time Insurance Co. United UnitedHealthCare Insurance Co.

The companies will be referenced by the abbreviations shown in bold face type. Some companies may be servicing existing business and not currently issuing new business.

5

Web Sites Company Name Web Site Address

Aetna Health, Inc of CT www.aetna.com Aetna Life Insurance Co. www.aetna.com Anthem Blue Cross & Blue Shield of CT, Inc. www.anthem.com Celtic Insurance Co. www.celtic-net.com CIGNA HealthCare of CT, Inc. www.cigna.com CIGNA Health & Life Insurance Company, Inc. www.cigna.com Connecticut General Life Insurance Co. www.cigna.com ConnectiCare, Inc. www.connecticare.com ConnectiCare Insurance Co. www.connecticare.com Golden Rule Insurance Co. www.goldenrule.com John Alden Life Insurance Co. www.assuranthealth.com Oxford Health Plans (CT), Inc. www.oxhp.com Oxford Health Insurance Co. www.oxhp.com Time Insurance Co. www.assuranthealth.com UnitedHealthcare Insurance Co. www.uhc.com

Note: Individuals may also contact a producer in their area for additional assistance in finding health insurance coverage.

6

Health Maintenance Organizations

HMO Address

CUSTOMCustomer Service

Phone Number

ER SERVICE INFORMATION Days of the week the

phone is staffed Hours the phone

is staffed

Does the HMO market to

individuals?

Aetna Health, Inc.

Anthem Blue Cross & Blue Shield of CT, Inc.

151 Farmington Ave. Hartford, CT 06156

108 Leigus Road Walingford, CT 06492

1-877-402-8742

multiple numbers

Monday-Friday

Monday-Friday

8:00am-6:00pm

8:00am-5:00pm

No

Yes

CIGNA HealthCare of CT., Inc.

ConnectiCare, Inc.

900 Cottage Grove Road Bloomfield, CT 06002

175 Scott Swamp Road Farmington, CT 06032

1-800-244-6224

1-800-251-7722 and 860-674-5757

Monday-Sunday

Monday-Friday

24 hours per day

Mon-Thu 8:00am-6:00pm Fri 8:00am-5:00pm

No

Yes

Oxford Health Plans (CT), Inc. 48 Monroe Turnpike Trumbull, CT 06611

1-800-444-6222 (member) 1-800-666-1353 (provider)

Monday-Friday 8:00am-6:00pm No

7


Fully Insured Enrollment

Other Enrollment Total Enrollment

Level of NCQA Accreditation

Achieved1

30,384 2,517 32,901 Excellent

103,253 185,608 288,861 Excellent

192 0 192 Commendable

99,535 0 99,535 Excellent

22.961 0 22,961 Commendable

1) National Committee for Quality Assurance (NCQA) - A not-for-profit organization that reviews quality and performance measures of HMOs and health plans, providing an independent standard of accountability.

Levels of Accreditation

Excellent - awarded to Organizations with programs for service and clinical quality that meet or exceed rigorous requirements for consumer protection and quality improvement. The organization must also achieve HEDIS results in the highest range of performance.

Commendable - awarded to organizationswith well-established programs for service and clinical quality that meet rigorous requirements for consumer protection and quality improvement.

Accredited - awarded to organizations with programs for service and clinical quality that meet basic requirements for consumer protection and quality improvement. Organizations awarded this status must take further action to achieve a higher accreditation status.

Provisional - awarded to organizations with programs for service and clinical quality that meet basic requirements for consumer protection and quality improvement. Organizations awarded this status must take significant action to achieve a higher accreditation status.

Denied - given to an organization whose programs for service and clinical quality did not meet NCQA requirements during the Accreditation sur vey.

NA - the health plan has not applied for NCQA accreditation.

8

Indemnity Managed Care Organizations

Managed Care Organization Address

CUSTO

Phone Number

MER SERVICE INFORMATION Days of the week the

phone is staffed Hours Staffed (eastern time)

Aetna Life Insurance Company 151 Farmington Ave. Hartford, CT 06156

1-800-962-6842 Monday-Friday 8:00am-6:00pm

Anthem Blue Cross & Blue Shield of CT, Inc. 108 Leigus Road Walingford, CT 06492

multiple numbers Monday-Friday 8:00am-5:00pm

Celtic Insurance Company 233 So. Wacker Dr., Ste. 700 Chicago, IL 60606-6393


CIGNA Health & Life Insurance Company, Inc. 900 Cottage Grove Road

Bloomfield, CT 06002

1-800-244-6224 Monday-Sunday 24 hours per day

ConnectiCare Insurance Company Inc. 175 Scott Swamp Road 1-800-251-7722 and Monday-Friday Mon-Thu 8:00am-6:00pm Farmington, CT 06032 860-674-5757 Fri 8:00am-5:00pm

Connecticut General Life Insurance Company 900 Cottage Grove Road Hartford, CT 06152

1-800-244-6224 Monday-Sunday 24 hours per day

Golden Rule Insurance Company 7440 Woodland Drive 1-800-657-8205 Monday-Friday Mon-Thu 8:00am-7:00pm Indianapolis, IN 46278-1719 Fri 8:00am-6:00pm

John Alden Life Insurance Company 501 West Michigan St. Milwaukee, WI 53201-3050


Oxford Health Insurance, Inc. 48 Monroe Turnpike Trumbull, CT 06611

1-800-444-6222 (member) 1-800-666-1353 (provider)

Monday-Friday 8:00am-6:00pm

Time Insurance Company 501 West Michigan St. Milwaukee, WI 53201


UnitedHealthCare Insurance Company 185 Asylum Avenue Hartford, CT 06103-3408


Note: Some Companies may be servicing existing business and not currently issuing new business.

9


Does the plan market to

individuals?

Fully Insured

Enrollment Other

Enrollment Total

Enrollment1

Level of NCQA Accreditation

Achieved

Yes 86,241 195,954 282,195 Excellent

Yes 201,700 709,615 911,315 NA

Yes 539 0 539 NA

No 41,436 176,148 217,584 Excellent

Yes 57,316 31,553 88,869 NA

Yes 37,556 337,969 375,525 Excellent

Yes 19,518 0 19,518 NA

Yes 250 0 250 NA

No 60,059 0 60,059 Commendable

Yes 1,496 113 1,609 NA

No 110,628 0 100,628 Commendable

1) National Committee for Quality Assurance (NCQA) - A not-for-profit organization that reviews quality and performance measures of HMOs and health plans, providing an independent standard of accountability.

Levels of Accreditation

Excellent - awarded to Organizations with programs for service and clinical quality that meet or exceed rigorous requirements for consumer protection and quality improvement. The organization must also achieve HEDIS results in the highest range of performance.

Commendable - awarded to organizationswith well-established programs for service and clinical quality that meet rigorous requirements for consumer protection and qualit y improvement.

Accredited - awarded to organizations with programs for service and clinical quality that meet basic requirements for consumer protection and quality improvement. Organizations awarded this status must take further action to achieve a higher accreditation status.

Provisional - awarded to organizations with programs for service and clinical quality that meet basic requirements for consumer protection and quality improvement. Organizations awarded this status must take significant action to achieve a higher accreditation status.

Denied - given to an organization whose programs for service and clinical quality did not meet NCQA requirements during the Accreditation survey.

NA - the health plan has not applied for NCQA accreditation.

1Only applies to managed care plans issued in Connecticut.

10

Health Maintenance Organizations Number of Providers Located in Each Connecticut County

HMO

Aetna Health

Anthem BC-BS

CIGNA

ConnectiCare

Oxford

Fairfield County PR

IMAR

Y CA

REPH

YSIC

IANS

PHYS

ICIA

NSP

ECIA

LIST

S

HOSP

ITAL

S

PHAR

MAC

IES

973 2,030 6 156

750 1,664 6 158

1,132 2,829 6 155

1,085 1,754 6 155

892 1,684 6 159

New Haven County

PRIM

ARY

CARE

PHYS

ICIA

NS

PHYS

ICIA

NSP

ECIA

LIST

S

HOSP

ITAL

S

PHAR

MAC

IES

1,107 2,562 7 173

718 2,398 7 174

1,098 3,637 7 172

1,382 2,953 7 174

957 2,172 7 172

Litchfield County

PRIM

ARY

CARE

PHYS

ICIA

NS

PHYS

ICIA

NSP

ECIA

LIST

S

HOSP

ITAL

S

PHAR

MAC

IES

151 424 3 41

109 181 3 38

151 424 3 40

138 216 3 39

131 287 3 41

Primary care physicians are defined as physicians practicing General Internal Medicine, General Practice, Family Practice, and General Pediatrics. OB/GYN physicians are not considered to be primary care physicians for this tabulation.

Listed above are the total number of primary care physicians, physician specialists, hospitals and pharmacies for each HMO provider network in Fairfield, New Haven and Litchfield counties. If an individual physician practices in more than one office, the physician is only counted once. Physicians who practice in more than one county were placed in the county that has the largest number of the HMO’s enrollees.

11


HMO

Aetna Health

Anthem BC-BS

CIGNA

ConnectiCare

Oxford

Hartford County

PRIM

ARY

CARE

PHYS

ICIA

NS

PHYS

ICIA

NSP

ECIA

LIST

S

HOSP

ITAL

S

PHAR

MAC

IES

1,031 2,202 7 179

835 2,144 7 175

1,098 3,278 7 171

1,399 3,122 7 173

955 1,868 7 177

Tolland County

PRIM

ARY

CARE

PHYS

ICIA

NS

PHYS

ICIA

NSP

ECIA

LIST

S

HOSP

ITAL

S

PHAR

MAC

IES

156 275 2 24

70 71 2 24

147 296 2 21

86 114 2 24

131 146 2 22

Middlesex County

PRIM

ARY

CARE

PHYS

ICIA

NS

PHYS

ICIA

NSP

ECIA

LIST

S

HOSP

ITAL

S

PHAR

MAC

IES

215 321 1 34

164 232 1 34

220 446 1 33

196 186 1 35

241 280 1 34


Listed above are the total number of primary care physicians, physician specialists, hospitals and pharmacies for each HMO provider network in Hartford, Tolland and Middlesex counties. If an individual physician practices in more than one office, the physician is only counted once. Physicians who practice in more than one county were placed in the county that has the largest number of the HMO’s enrollees.

12


HMO

Aetna Health

Anthem BC-BS

CIGNA

ConnectiCare

Oxford

New London County PR

IMAR

Y CA

REPH

YSIC

IANS

PHYS

ICIA

NSP

ECIA

LIST

S

HOSP

ITAL

S

PHAR

MAC

IES

221 579 2 48

192 383 2 48

202 635 2 48

215 493 2 48

214 374 2 49

Windham County

PRIM

ARY

CARE

PHYS

ICIA

NS

PHYS

ICIA

NSP

ECIA

LIST

S

HOSP

ITAL

S

PHAR

MAC

IES

133 213 2 22

78 137 2 22

134 252 2 22

114 134 2 22

120 177 2 22

TOTALS FOR ALL COUNTIES

PRIM

ARY

CARE

PHYS

ICIA

NS

PHYS

ICIA

NSP

ECIA

LIST

S

HOSP

ITAL

S

PHAR

MAC

IES

3,987

2,916

4,182

4,615

3,641

8,606

7,210

11,797

8,972

6,988

30

30

30

30

30

677

673

662

670

676


Listed above are the total number of primary care physicians, physician specialists, hospitals and pharmacies for each HMO provider network in New London and Windham counties. If an individual physician practices in more than one office, the physician is only counted once. Physicians who practice in more than one county were placed in the county that has the largest number of the HMO’s enrollees.

13

Indemnity Managed Care Organizations Number of Providers Located in Each Connecticut County*

Fairfield County New Haven County Litchfield County

Indemity Managed Care Organization PR

IMAR

Y CA

REPH

YSIC

IANS

PHYS

ICIA

NSP

ECIA

LIST

S

HOSP

ITAL

S

PHAR

MAC

IES

PRIM

ARY

CARE

PHYS

ICIA

NS

PHYS

ICIA

NSP

ECIA

LIST

S

HOSP

ITAL

S

PHAR

MAC

IES

PRIM

ARY

CARE

PHYS

ICIA

NS

PHYS

ICIA

NSP

ECIA

LIST

S

HOSP

ITAL

S

PHAR

MAC

IES

Aetna Life 973 2,032 6 156 1,107 2,566 7 173 151 426 3 41

Anthem BC-BS 775 1,724 6 158 730 2,454 7 174 112 188 3 38

Celtic 651 1,309 6 160 874 1,988 7 179 92 199 3 39

CIGNA H&L 1,132 2,829 6 155 1,098 3,637 7 172 151 424 3 40

ConnectiCare 1,085 1,754 6 155 1,382 2,953 7 174 138 216 3 39

CT General 1,132 2,829 6 155 1,098 3,637 7 172 151 424 3 40

Golden Rule 892 1,684 6 159 957 2,172 7 172 131 287 3 41

John Alden 651 1,309 6 162 874 1,988 7 173 92 199 3 41

Oxford Health 892 1,684 6 159 957 2,172 7 172 131 287 3 41

Time 651 1,309 6 167 874 1,988 7 173 92 199 3 41

United 892 1,684 6 159 957 2,172 7 172 131 287 3 41


Listed above are the total number of primary care physicians, physician specialists, hospitals, and pharmacies for each MCO provider network in Fairfield, New Haven and Litchfield counties. If an individual physician practices in more than one office, the physician is counted once. Physicians who practice in more than one county were placed in the county that has the largest number of the MCO’s enrollees.

*If a MCO utilizes more than one provider network, the network containing the least number of primary care physicians is represented.

14


Hartford County Tolland County Middlesex County

Indemity Managed Care Organization PR

IMAR

Y CA

REPH

YSIC

IANS

PHYS

ICIA

NSP

ECIA

LIST

S

HOSP

ITAL

S

PHAR

MAC

IES

PRIM

ARY

CARE

PHYS

ICIA

NS

PHYS

ICIA

NSP

ECIA

LIST

S

HOSP

ITAL

S

PHAR

MAC

IES

PRIM

ARY

CARE

PHYS

ICIA

NS

PHYS

ICIA

NSP

ECIA

LIST

S

HOSP

ITAL

S

PHAR

MAC

IES

Aetna Life 1,031 2,212 7 179 156 277 2 24 215 320 1 34

Anthem BC-BS 841 2,204 7 175 72 74 2 24 166 245 1 34

Celtic 834 1,782 7 184 69 88 2 24 122 172 1 38

CIGNA H&L 1,098 3,278 7 171 147 296 2 21 220 446 1 33

ConnectiCare 1,399 3,122 7 173 86 114 2 24 196 186 1 35

CT General 1,098 3,278 7 171 147 296 2 21 220 446 1 33

Golden Rule 955 1,868 7 177 131 146 2 22 241 280 1 34

John Alden 834 1,782 7 176 69 88 2 22 122 172 1 34

Oxford Health 955 1,868 7 177 131 146 2 22 241 280 1 34

Time 834 1,782 7 176 69 88 2 22 122 172 1 34

United 955 1,868 7 177 131 146 2 22 241 280 1 34


Listed above are the total number of primary care physicians, physician specialists, hospitals, and pharmacies for each MCO provider network in Hartford, Tolland and Middlesex counties. If an individual physician practices in more than one office, the physician is counted once. Physicians who practice in more than one county were placed in the county that has the largest number of the MCO’s enrollees.


15


New London County Windham County TOTALS FOR ALL COUNTIES

PRIM

ARY

CARE

PHYS

ICIA

NS

PHYS

ICIA

NSP

ECIA

LIST

S

HOSP

ITAL

S

PHAR

MAC

IES

PRIM

ARY

CARE

PHYS

ICIA

NS

PHYS

ICIA

NSP

ECIA

LIST

S

HOSP

ITAL

S

PHAR

MAC

IES

PRIM

ARY

CARE

PHYS

ICIA

NS

PHYS

ICIA

NSP

ECIA

LIST

S

HOSP

ITAL

S

PHAR

MAC

IES

Indemity Managed Care Organization

Aetna Life 221 580 2 48 133 213 2 22 3,987 8,626 30 677

Anthem BC-BS 196 399 2 48 78 146 2 22 2,970 7,434 30 673

Celtic 136 314 2 49 65 105 2 23 2,843 5,957 30 696

CIGNA H&L 202 635 2 48 134 252 2 22 4,182 11,797 30 662

ConnectiCare 215 493 2 48 114 134 2 22 4,615 8,972 30 670

CT General 202 635 2 48 134 252 2 22 4,182 11,797 30 662

Golden Rule 214 374 2 49 120 177 2 22 3,641 6,988 30 676

John Alden 136 314 2 49 65 105 2 21 2,843 5,957 30 678

Oxford Health 214 374 2 49 120 177 2 22 3,641 6,988 30 676

Time 136 314 2 49 65 105 2 21 2,843 5,957 30 683

United 214 374 2 49 120 177 2 22 3,641 6,988 30 676


Listed above are the total number of primary care physicians, physician specialists, hospitals, and pharmacies for each MCO provider network in New London and Windham counties. If an individual physician practices in more than one office, the physician is counted once. Physicians who practice in more than one county were placed in the county that has the largest number of the MCO’s enrollees.


16

Quality Measures

Percentage of Primary Care Physicians Who Are Board Certified

The percentage of primary care physicians in the HMO’s provider network

who were board certified as of December 31, 2012.

Connecticut HMO Average

Aetna Health

Anthem BC-BS

CIGNA

ConnectiCare

Oxford

85.12%

86.27%

80.95%

87.48%

89.30%

81.61%

Percentage of Physician Specialists Who Are Board Certified

The percentage of physician specialists in the HMO’s provider network


Connecticut HMO Average 79.94%

Aetna Health 78.25%

Anthem BC-BS 82.88%

CIGNA 71.63%

ConnectiCare 88.10%

Oxford 78.82%

17

Quality Measures

Breast Cancer Screening

The percentage of enrolled women who: (a) were age 40 through 69 years as of

December 31, 2012; and (b) were continuously enrolled during 2011 and 2012;

and (c) had a mammogram during 2011 or 2012.


Aetna Health 73.43%

Anthem BC-BS 78.88%

CIGNA 73.41%

ConnectiCare 74.10%

Oxford 73.49%

Cervical Cancer Screening


December 31, 2012; and (b) were continuously enrolled during 2010, 2011or

2012; and (c) received one or more Pap tests during 2010, 2011 or 2012.


Aetna Health 78.56%

Anthem BC-BS 83.48%

CIGNA 81.38%

ConnectiCare 79.73%

Oxford 83.03%

18

Quality Measures

Colorectal Cancer Screening

The percentage of members 51-75 who had one or more screenings for colorectal

cancer. Appropriate screenings are defined by any of the following criteria:

a) Fecal occult blood test (FOBT) during 2012.

b) Flexible sigmoidoscopy during 2012 or the 4 years prior to 2012.

c) Colonoscopy during 2012 or the 9 years prior to 2012.


Aetna Health 66.09%

Anthem BC-BS 73.91%

CIGNA 66.49%

ConnectiCare 63.93%

Oxford 64.68%

Controlling High Blood Pressure

The percentage of members who: (a) were age 18 through 85 years as of

December 31, 2012; and (b) were diagnosed with hypertension (HTN); and (c)

whose blood pressure was adequately controlled (<140/90) during 2012.

52.56%Connecticut HMO Average

Aetna Health 62.66%

Anthem BC-BS 64.66%

CIGNA 0.00%

ConnectiCare 76.11%

Oxford 59.36%

19

Quality Measures

Cholesterol Management for Patients with Cardiovascular Disease The percentage of enrolled members age 18 through 75 years as of December 31,

2012 who: (a) were discharged alive for acute myocardial infarction, coronary

artery bypass graft, or percutaneous coronary interventions between January 1

and November 1, 2011; or (b) who had a diagnosis of ischemic vascular disease

during 2012 or 2011; and (c) who had a LDL-C screening and an LDL-C control

(<100mg/dl) during 2012


Aetna Health 54.73%

Anthem BC-BS 71.77%

CIGNA 0.00%

ConnectiCare 29.07%

Oxford 58.02%

Childhood Immunizations

The percentage of enrolled children who: (a) turned two years old during 2012;

and (b) were continuously enrolled for the 12 months preceding their second

birthday; and (c) have received recommended immunizations. Immunizations

for polio, measles, mumps, rubella, influenza type b, hepatitis b, diphtheria,

tetanus, pertussis, chicken pox, pneumococcal, hepatitus a and rotavirus are

included in this measure.


Aetna Health 45.35%

Anthem BC-BS 25.23%

CIGNA 0.00%

ConnectiCare 53.85%

Oxford 22.49%

20

Quality Measures

Prenatal Care in the First Trimester

The percentage of enrolled women who: (a) delivered a live birth between

November 6, 2011 and November 5, 2012; and (b) were continuously enrolled for

43 days prior to delivery through 56 days after delivery; and had at least one pre

natal care visit in the first trimester or within 42 days of enrollment in the

Managed Care Organization.


Aetna Health 93.46%

Anthem BC-BS 98.11%

CIGNA 73.81%

ConnectiCare 87.25%

Oxford 93.17%

Postpartum Care Following Delivery


November 6, 2011 and November 5, 2012; and (b) were continuously enrolled for

43 days prior to delivery through 56 days after delivery; and had a postpartum

visit on or between 21 days and 56 days after delivery.


Aetna Health 79.91%

Anthem BC-BS 93.08%

CIGNA 0.00%

ConnectiCare 95.97%

Oxford 84.34%

21

Quality Measures

Adult Access to Care

The percentage of enrollees ages 20-44 and 45-64 as of December 31, 2012

who (a) were continuously enrolled in the plan during 2010, 2011 and 2012; and

(b) have had at least one ambulatory or preventive care visit with a health plan

provider during 2010, 2011 or 2012.

Connecticut HMO Average 95.91%, 97.49%

Aetna Health

Anthem BC-BS

CIGNA

ConnectiCare

Oxford

94.84%, 96.63%

97.43%, 98.49%

96.37%, 97.62%

94.59%, 96.91%

96.31%, 97.79%

Age 20-44

Age 45-64

Eye Exams for People with Diabetes

The percentage of all members with diabetes (type II and I) who: (a) were enrolled

on December 31, 2012; and (b) turned 18 through 75 years of age during 2012;

and (c) were continuously enrolled during 2012; and (d) had either a retinal or

dilated eye examination in 2012, or had a negative retinal or dilated eye exami

nation in 2011.


Aetna Health

Anthem BC-BS

CIGNA

ConnectiCare

Oxford

63.43%

72.63%

49.66%

65.32%

61.57%

22

Quality Measures

Beta Blocker Treatments after a Heart Attack

The percentage of all members who: (a) were age 18 years and older as of

December 31, 2012; and (b) were hospitalized and discharged alive between July

1, 2011 and June 30, 2012; and (c) had a diagnosis of Acute Myocardial

Infarction (AMI); and (d) received persistant beta-blocker treatment for 6

months after discharge.


Aetna Health 78.57%

Anthem BC-BS 44.51%

CIGNA 0.00%

ConnectiCare 92.14%

Oxford 0.00%

Outpatient Drug Utilization for Managed Care Enrollees

Total cost of Average Average annual Percentage

prescriptions cost per number of of reported

in 2012 prescription prescriptions plans with

per member prescription

per year coverage

Aetna Health $45,695,191 $74.04 11.43 97.17% Anthem BC-BS $156,291,804 $90.11 13.81 46.10% CIGNA $5,210,134 $91.01 11.23 99.00% ConnectiCare $138,357,332 $69.52 13.07 99.00% Oxford $21,105,835 $88.95 10.83 98.52%

23

Quality Measures

Percentage of Primary Care Physicians Who Are Board Certified

The percentage of primary care physicians in the MCO’s provider network


CT Indemnity MCO Average

Aetna Life

Anthem BC-BS

Celtic

CIGNA H & L

ConnectiCare

CT General

Golden Rule

John Alden

Oxford Health

Time

United

83.94%

86.24%

80.42%

81.00%

87.00%

89.30%

87.23%

86.90%

81.00%

81.61%

81.00%

81.61%

Percentage of Physicians Specialist Who Are Board Certified

The percentage of physician specialists in the MCO’s provider

network who were board certified as of December 31, 2012.


Aetna Life

Anthem BC-BS

Celtic

CIGNA H & L

ConnectiCare

CT General

Golden Rule

John Alden

Oxford Health

Time

United

79.25%

77.93%

82.47%

75.00%

76.54%

88.10%

76.94%

87.17%

75.00%

78.82%

75.00%

78.82%

24

Quality Measures

Breast Cancer Screening


December 31, 2012; and (b) were continuously enrolled during 2011 and 2012;

and (c) had a mammogram during 2011 or 2012.


Aetna Life

Anthem BC-BS

Celtic 24.15%

CIGNA H & L

ConnectiCare

CT General

Golden Rule

John Alden

Oxford Health

Time

United

64.50%

73.14%

72.01%

74.32%

76.53%

74.28%

51.08%

60.00%

71.65%

59.00%

73.35%

Cervical Cancer Screening


December 31, 2012; and (b) were continuously enrolled during 2010, 2011 or

2012; and (c) received one or more Pap tests during 2010, 2011 or 2012.

CT Indemnity MCO 62.60% Average

Aetna Life 79.41%

Anthem BC-BS 77.53%

Celtic 12.85%

CIGNA H & L 79.03%

ConnectiCare 80.23%

CT General 79.17%

Golden Rule 17.41%

John Alden 55.00%

Oxford Health 80.16%

Time 49.00%

United 78.82%

25

Quality Measures

Colorectal Cancer Screening

The percentage of members age 51-75 who had one or more screenings for col

orectal cancer. Appropriate screenings are defined by any of the following criteria:

a) Fecal occult blood test (FOBT) during 2012.

b) Flexible sigmoidoscopy during 2012 or the 4 years prior to 2012.

c) Colonoscopy during 2012 or the 9 years prior to 2012.


Aetna Life 67.15%

Anthem BC-BS 60.65%

Celtic 11.45%

CIGNA H & L 69.63%

ConnectiCare 65.67%

CT General 67.00%

Golden Rule 9.17%

John Alden 27.00%


Time 28.00%

United 67.76%


Aetna Life

Anthem BC-BS

Celtic

CIGNA H & L

ConnectiCare

CT General

Golden Rule

John Alden

Oxford Health

Time

United

Controlling High Blood Pressure

The percentage of members who: (a) were age 18 through 85 years as of

December 31, 2012; and (b) were diagnosed with hypertension (HTN); and (c)

whose blood pressure was adequately controlled (<140/90) during 2012.

34.73%

65.16%

0.00%

0.00%

61.97%

81.67%

61.97%

0.00%

10.00%

45.88%

6.00%

49.38%

26

Quality Measures

Cholesterol Management for Patients with Cardiovascular Disease

The percentage of enrolled members age 18 through 75 years as of December 31,

2012 who; (a) were discharged alive for acute myocardial infarction, coronary

artery bypass graft, or percutaneous coronary interventions between January 1

and November 1, 2011; or (b) who had a diagnosis of ischemic vascular disease

during 2012 or 2011; and (c) who had a LDL-C screening and an LDL-C control

(<100mg/dl) during 2012.


Aetna Life 54.83%

Anthem BC-BS 12.78%

Celtic 0.00%

CIGNA H & L 65.23%

ConnectiCare 36.04%

CT General 65.23%

Golden Rule 0.00%

John Alden 0.00%


Time 0.00%

United 59.67%

Childhood Immunizations

The percentage of enrolled children who: (a) turned two years old during 2012;

and (b) were continuously enrolled for the 12 months preceding their second

birthday; and (c) have received recommended immunizations. Immunizations

for polio, measles, mumps, rubella, influenza type b, hepatitis b, diphtheria,

tetanus, pertussis, chicken pox, pneumococcal, hepatitis a and rotavirus are

included in this measure.


Aetna Life 50.71%

Anthem BC-BS 9.00%

Celtic 0.00%

CIGNA H & L 20.68%

ConnectiCare 48.19%

CT General 20.68%

Golden Rule 0.00%

John Alden 0.00%


Time 0.00%

United 19.33%

27

Quality Measures

Prenatal Care in the First Trimester


November 6, 2011 and November 5, 2012; and (b) were continuously enrolled

for 43 days prior to delivery through 56 days after delivery; and had at least

one prenatal care visit in the first trimester or within 42 days of enrollment

in the Managed Care Organization.

64.29% Average

Aetna Life

CT Indemnity MCO

95.33%

Anthem BC-BS 54.93%

Celtic 0.00%

CIGNA H & L 95.43%

ConnectiCare 94.87%

CT General 86.05%

Golden Rule 92.31%

John Alden 0.00%


Time 0.00%

United 96.20%

Postpartum Care Following Delivery


November 6, 2011 and November 5, 2012; and (b) were continuously

enrolled for 43 days prior to delivery through 56 days after delivery; and

had a postpartum visit on or between 21 days and 56 days after delivery.


Aetna Life 88.32%

Anthem BC-BS 44.60%

Celtic 0.00%

CIGNA H & L 84.47%

ConnectiCare 87.18%

CT General 84.47%

Golden Rule 50.00%

John Alden 0.00%


Time 0.00%

United 85.93%

28

Quality Measures

Adult Access to Care

The percentage of enrollees ages 20-44 and 45-64 as of December 31, 2012 who:

(a) were continuously enrolled in the plan during 2010, 2011 and 2012; and

(b) have had at least one ambulator y or preventive care visit with a health plan

provider during 2010, 2011 or 2012.

CT Indemnity MCO 83.25, 86.34% Average

Aetna Life 94.78%, 96.58% Anthem BC-BS 94.89%,96.69% Celtic 10.78%, 15.18% CIGNA H & L 95.41%,97.10% ConnectiCare 94.52%,96.86% CT General 95.48%,97.12% Golden Rule 76.06%,66.88% John Alden 95.00%,97.00% Oxford Health 94.25%,95.85% Time 70.00%,94.00% United 94.57%, 96.53%

Age 20-44

Age 45-64

Eye Exams for People with Diabetes

The percentage of all members with diabetes (type II and I) who: (a) were

enrolled on December 31, 2012; and (b) turned 18 through 75 years of age

during 2012; and (c) were continuously enrolled during 2012; and (d) had either

a retinal or dilated eye examination in 2012, or had a negative retinal or dilated

eye examination in 2011.


Aetna Life 62.73%

Anthem BC-BS 44.32%

Celtic 0.00%

CIGNA H & L 63.26%

ConnectiCare 61.24%

CT General 57.50%

Golden Rule 0.09%

John Alden 50.00%


Time 50.00%

United 64.27%

29

Quality Measures

Beta Blocker Treatments after a Heart Attack

The percentage of all members who: (a) were age 18 years and older as of

December 31, 2012; and (b) were hospitalized and discharged alive between July

1, 2011 and June 30, 2012; and (c) had a diagnosis of Acute Myocardial

Infarction (AMI); and (d) received persistant beta-blockers treatment for 6

months after discharge.


Aetna Life 88.51%

Anthem BC-BS 42.57%

Celtic 0.00%

CIGNA H & L 71.05%

ConnectiCare 97.44%

CT General 70.88%

Golden Rule 0.05%

John Alden 0.00%


Time 0.00%

United 76.60%

Outpatient Drug Utilization for Managed Care Enrollees

Total cost of Average Average annual Percentage

prescriptions cost per number of of reported

in 2012 prescription prescriptions plans with

per member prescription

per year coverage

Aetna Life $132,545,499 $76.99 11.03 97.17%

Anthem BC-BS $299,781,669 $80.51 13.42 37.90%

Celtic $473,963 $109.82 9.45 100.00%

CIGNA H & L $141,520,001 $87.80 11.78 95.00%

ConnectiCare $40,375,722 $65.80 12.15 99.00%

CT General $73,365,068 $88.01 11.51 95.00%

Golden Rule $6,066,192 $55.85 26.80 88.40%

John Alden $180,196 $72.46 8.66 100.00%

Oxford Health $69,884,762 $87.74 11.02 98.01%

Time $688,605 $73.62 6.22 100.00%

United $67,363,679 $88.02 11.12 100.00%

30

Health Maintenance Organizations Utilization Review Measures

Utilization Review (UR) is the process by which your health plan determines whether the treatment or services prescribed by your physician are appropriate or medically nec

essary to treat your condition. Your health plan may contract with a licensed specialty utilization review company to review recommended treatment for specific types of serv

ices (i.e. behavioral health, diagnostic services, prescription drugs, etc.).

For purposes of understanding the charts below, a higher percentage of UR denials means that more requests for prescribed treatment were denied, in whole or in part, by the

health plan when compared to other plans.

Conversely, a lower percentage of UR denials when compared to other health plans means that more requests for services were approved by the health plan.

HMO Aetna Anthem BC-BS CIGNA ConnectiCare Oxford

Total number or UR requests

Total number of UR denials

Percentage of UR requests denied

Total number of UR denials that were appealed

Total number of denials that were reversed on appeal Percentage of denials that were reversed on appeal

Total number of denials that were appealed, upheld and went to external appeal Total number of external appeals that were reversed Percentage of external appeals that were reversed

15,847

1,479

9%

510

158

31%

3

1

33%

75,738

2,755

4%

406

226

56%

15

7

47%

305

106

35%

6

2

33%

0

0

0%

48,672

4,577

9%

369

136

37%

31

8

26%

19,529

1,997

10%

251

144

57%

10

3

30%

31

Indemnity Managed Care Organizations Utilization Review Measures


Aetna Life

Anthem BC-BS

Celtic CIGNA H & L

ConnectiCare CT General

Golden Rule

John Alden

Oxford Health

Time United

Total number or UR requests 21,600 73,801 71 8,574 17,418 51,729 23 17 44,279 59 1,969


Percentage of UR requests

1,718 4,697 5 1,875 1,653 22,959 14 2 5,079 8 75

denied


8% 6% 7% 22% 9% 44% 61% 12% 11% 14% 4%

that were appealed

Total number of denials that

744 571 1 31 123 217 1 2 547 2 49

were reversed on appeal

Percentage of denials that were

201 276 0 12 60 61 0 0 293 1 21

reversed on appeal

Total number of denials that

27% 48% 0% 39% 49% 28% 0% 0% 54% 50% 43%

were appealed, upheld and went to external appeal

3 33 0 1 10 16 0 1 11 0 3

Total number of external appeals that were reversed

1 9 0 1 2 4 0 1 2 0 0

Percentage of external appeals that were reversed

33% 27% 0% 100% 20% 25% 0% 100% 18% 0% 0%

32

Health Maintenance Organizations Fully Insured Behavioral Health - Utilization Review Statistics

Provide the following on all fully-insured mental & nervous conditions for calendar year 2012.

Aetna Health

Anthem BC-BS

CIGNA ConnectiCare Oxford

1)Number of UR request received a) Inpatient Admissions 311 554 6 576 108 b) Outpatient Services 223 980 1 3,572 91 c) Procedures 9 0 0 0 1 d) Extensions of Stay 380 649 13 865 108

2)Number of Total Denials a) Inpatient Admissions 11 64 0 2 12 b) Outpatient Services 6 11 0 81 2 c) Procedures 1 0 0 0 0 d) Extensions of Stay 0 58 2 28 12

3)Number of Partial Denials a) Inpatient Admissions 0 1 0 1 10 b) Outpatient Services 0 1 0 10 0 c) Procedures 0 0 0 0 0 d) Extensions of Stay 16 0 0 12 10

4)Number of Appeals of Denials a) Inpatient Admissions 1 53 1 1 0 b) Outpatient Services 3 8 0 9 7 c) Procedures 0 0 0 0 0 d) Extensions of Stay 0 0 0 1 0

5)Number of Denials Reversed on Appeal a) Inpatient Admissions 0 3 0 0 0 b) Outpatient Services 1 7 0 1 0 c) Procedures 0 0 0 0 0 d) Extensions of Stay 0 0 0 0 0

6)Number of upheld appeals that went to external appeal a) Inpatient Admissions 0 3 0 1 2 b) Outpatient Services 1 6 0 2 0 c) Procedures 0 0 0 0 0 d) Extensions of Stay 0 0 0 2 2

7)Number of External Appeals Reversed on Appeal a) Inpatient Admissions 0 1 0 1 0 b) Outpatient Services 0 5 0 0 0 c) Procedures 0 0 0 0 0 d) Extensions of Stay 0 0 0 0 0

33


Mental Health Utilization Inpatient Discharges & Average Length of Stays

Aetna Health

Anthem BC-BS


Report the total number of inpatient discharges with mental health as the principal diagnosis at either a hospital or a treatment facility.

Report the total discharges / 1,000 member months* *for Medicaid. Commercial & Medicare use: discharges / 1,000 members per year

Report the average length of stay.

197

3.01

8.27

1,065

4.16

7.70

24

0.16

15.20

465

0.25

8.19

198

0.34

11.93

Mental Health Utilization Percentage by Level of Care

Aetna Health

Anthem BC-BS


Report the total number of members who received care A) Any Mental Health Service 4,091 32,911 503 11,752 4,745 B) Inpatient Mental Health Services 102 812 14 375 152 C) Intensive Outpatient or Partial Hospitalization

Health Services 92 587 8 154 101

D) Outpatient or Emergency Department Health Services

Report the percentage of the above numbers who received the respective service.

4,067 32,797 498 11,700 4,716

A) Inpatient Mental Health Services 0.23% 0.31% 0.23% 0.20% 0.32% B) Intensive Outpatient or Partial Hospitalization

Health Services 0.21% 0.23% 0.13% 0.08% 0.21%

C) Outpatient or Emergency Department Health Services 9.37% 12.62% 8.07% 6.10% 9.84%

34


Chemical Dependency Utilization Inpatient Discharges & Average Length of Stays

Aetna Health

Anthem BC-BS


Report the total number of inpatient discharges with chemical dependency as the principal diagnosis, including detoxification, at either a hospital or a treatment facility.

Report the total discharges / 1,000 member months* *for Medicaid. Commercial & Medicare use: discharges / 1,000 members per year

Report the average length of stay.

82

1.25

4.63

617

2.41

5.40

18

0.12

6.94

303

0.16

5.50

225

4.70

4.81

Alcohol & Other Drug Services Percentage by Level of Care

Aetna Health

Anthem BC-BS


Report the total number of members who received care a) Any Chemical Dependency Service 749 5,120 79 2,325 957 b) Inpatient Chemical Dependency Services c) Intensive Outpatient or Partial Hospitalization

155 1,091 15 453 289

Dependency Services 101 634 7 148 137 d) Outpatient or Emergency Department Dependency Services

Report the percentage of the above numbers who received the respective service.

663 4,578 73 2,157 793

a) Inpatient Chemical Dependency Services b) Intensive Outpatient or Partial Hospitalization

0.36% 0.42% 0.24% 0.24% 0.60%

Dependency Services 0.23% 0.24% 0.11% 0.08% 0.29% d) Outpatient or Emergency Department Dependency Services 1.53% 1.76% 1.18% 1.12% 1.65%

35


Mental Health Utilization Follow-up After Hospitalization for Mental Illness

Aetna Health

Anthem BC-BS


The percentage of discharges from an inpatient setting of an acute care facility, including acute psychiatric facilities, with a discharge date on or between Jan. 1 and Dec 1, 2012 for members 6 yrs of age or older who were hospitalized for treatment of select mental health disorders.

a) Who had an outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health practioner on the date of discharge up to 30 days after the hospital discharge.

b)Who had an outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health practioner on the date of discharge up to 7 days after the hospital discharge.

77.78%

71.11%

79.68%

64.94%

0.00%

0.00%

83.55%

71.62%

85.37%

70.73%

Mental Health Utilization Antidepressant Medication Management

Aetna Health

Anthem BC-BS


The percentage of members 18 and older as of Apr. 30, 2012, who were continuously enrolled 90 days prior to the episode start date through 245 days after the start date, who were diagnosed with a new episode of depression between May 1, 2011 and Apr. 30, 2012, and treated with antidepressant medication, who met at least one of the following criteria during the intake period.

* At least one principal diagnosis of major depression in an outpatient, ED, intensive outpatient or partial hospitalization; or * At least two visits in an outpatient, ED, intensive outpatient or partial hospitalization setting on different dates of service with any diagnosis of major depression; or * At least one inpatient claim/encounter with any diagnosis of major depression.

a) Who remained on antidepressant medication for at least an 84-day period (12 week) acute treatment phase. b)Who remained on antidepressant medication for at

77.57% 71.63% 0.00% 69.43% 66.17%

least 180 days (6 months) continuation phase. 61.22% 56.62% 0.00% 53.68% 54.14%

36


Claim Expenses - Aetna Health

Anthem BC-BS


Provide the claim expenses on a per member per month basis for the period of Jan. 1, 2012 through Dec. 31, 2012 for each of the following.

Inpatient Mental Health Inpatient Substance Abuse Outpatient Mental Health Outpatient Substance Abuse Total of the above overall

$4.89 $1.11 $5.87 $1.49

$13.36

$2.80 $0.42 $8.18 $1.15

$12.55

$8.86 $0.62 $2.92 $0.15

$12.55

$2.87 $0.88 $3.95 $1.18 $8.88

$3.07 $0.91 $8.04 $0.79

$12.81

Claim Denial Data - Aetna Health

Anthem BC-BS


For the period of Jan.1, 2012 through Dec. 31, 2012. 129,292 1,305,916 5,028 3,742,937 935,016 The total number of claims received for that period.

Provide the number of denials of the total in each of the following: 1) not a covered benefit 35,035 15,383 65 21,154 13,449 2) not medically necessary 994 434 2 3,262 3,789 3) not an eligible enrollee/dependent 8,548 39,481 20 120,338 41,549 4) incomplete submission 0 9,779 86 48,628 82,455 5) duplicate submission 0 34,938 50 131,574 48,601 6) all other miscellaneous 84,715 134,677 152 322,188 60,132

Provide the denials as a percentage of the total in each of the following: 1) not a covered benefit 2.53% 1.18% 1.29% 0.57% 1.44% 2) not medically necessary 0.07% 0.05% 0.04% 0.09% 0.41% 3) not an eligible enrollee/dependent 0.62% 3.00% 0.40% 3.22% 4.44% 4) incomplete submission 0.00% 0.75% 1.71% 1.30% 8.82% 5) duplicate submission 0.00% 2.70% 1.00% 3.52% 5.20% 6) all other miscellaneous 6.13% 10.31% 3.01% 8.61% 6.43%

37

Indemnity Managed Care Companies Fully Insured Behavioral Health - Utilization Review Statistics Provide the following on all fully-insured mental & nervous conditions for calendar year 2012.

Aetna Life

Anthem BC-BS

Celtic CIGNA H&L


Golden Rule

John Alden

Oxford Health

Time United

1) Number of UR requests received a) Inpatient Admissions 330 665 0 126 252 216 0 1 285 10 16 b) Outpatient Services 266 1,321 0 125 1,816 252 0 0 181 0 26 c) Procedures 5 0 0 0 0 0 0 0 3 0 0 d) Extensions of Stay

2) Number of Total Denials 424 868 0 603 451 886 0 0 285 4 21

a) Inpatient Admissions 3 101 0 7 1 10 0 0 42 0 4 b) Outpatient Services 7 34 0 8 39 17 0 0 5 0 14 c) Procedures 1 0 0 0 0 0 0 0 0 0 0 d) Extensions of Stay

3)Number of Partial Denials 0 94 0 26 14 51 0 0 42 0 9


4) Number of Appeals of Denials 15 0 0 0 6 0 0 0 28 0 4


5) Number of Denials Reversed on Appeal 0 0 0 12 1 19 0 0 2 0 3


6) Number of upheld appeals that went to External Appeal

0 0 0 3 0 2 0 0 0 0 2


7) Number of external appeals reversed on appeal 0 0 0 0 2 2 0 0 3 0 0

a) Inpatient Admissions 0 1 0 0 0 0 0 0 0 0 0 b) Outpatient Services 0 9 0 0 1 2 0 0 0 0 0 c) Procedures 0 0 0 0 0 0 0 0 0 0 0 d) Extensions of Stay 0 0 0 0 0 2 0 0 0 0 0

38

Indemnity Managed Care Companies Mental Health Utilization - Inpatient Discharges & Average Length of Stays

Aetna Anthem Celtic CIGNA ConnectiCare CT Golden John Oxford Time United Life BC-BS H & L General Rule Alden Health

Report the total number of inpatient discharges with mental health as the principal diagnosis at either a hospital or a treatment facility. 342 1,390 0 722 126 746 106 0 269 6 552

Report the total discharges / 1,000 member mths* * for Medicaid. Commercial & Medicare use: 2.43 3.73 0.00 0.21 0.21 0.20 0.50 0.00 0.30 4.17 0.31 discharges / 1,000 members per year

Report the average length of stay. 7.87 8.60 0.00 9.38 9.33 9.56 7.00 0.00 8.16 25.00 9.09

Mental Health Utilization - Percentage by Level of Care Aetna Life

Anthem BC-BS

Celtic CIGNA H & L


Golden Rule

John Alden

Oxford Health

Time United

1)Report the total number of members who received

a) Any Mental Health Service b) Inpatient Mental Health

25,185 58,119 0 23,015 3,574 23,518 1,867 15 7,732 123 14,135

Services c) Intensive Outpatient or Partial

684 1,410 0 556 101 570 98 0 197 6 410

Hospitalization Health Services d) Outpatient or Emergency

543 1,098 0 458 43 466 0 0 152 0 334

Department Health Services

2)Report the percentage of the above numbers who received the respective service

25,056 57,687 0 22,915 3,558 23,413 1,847 14 7,688 121 14,074

a) Inpatient Mental Health Services b) Intensive Outpatient or Partial

0.24% 0.22% 0.00% 0.22% 0.15% 0.22% 5.25% 0.00% 0.26% 0.40% 0.27%

Hospitalization Health Services c) Outpatient or Emergency

0.19% 0.17% 0.00% 0.18% 0.07% 0.18% 0.00% 0.00% 0.20% 0.00% 0.22%

Department Health Services 8.89% 9.21% 0.00% 9.04% 5.08% 9.01% 98.93% 5.07% 10.33% 8.09% 9.35%

39

Indemnity Managed Care Companies Chemical Dependency Utilization - Inpatient Discharges & Average Length of Stays


Report the total number of inpatient discharges with chemical dependency as the principal diagnosis, including detoxification, at either a hospital or a treatment facility. 194 764 1 518 71 536 11 0 250 0 568

Report the total discharges / 1,000 member mths* * for Medicaid. Commercial & Medicare use: 1.38 2.05 0.02 0.15 0.12 0.14 0.05 0 0.28 0 0.22 discharges / 1,000 members per year

Report the average length of stay. 5.01 5.50 2.00 5.90 5.63 5.94 4.00 0.00 4.31 0.00 6.45

Alcohol & Other Drug Services - Percentage by Level of Care Aetna Life

Anthem BC-BS

Celtic CIGNA H & L


Golden Rule

John Alden

Oxford Health

Time United

1)Report the total number of members who received care

a) Any Chemical Dependency Service 4,064 9,152 1 3,272 636 3,351 229 2 1,149 8 2,183 b) Inpatient Chemical Dependency Services c) Intensive Outpatient or Partial

929 1,934 1 696 110 711 29 0 303 0 568

Hospitalization Health Services d) Outpatient or Emergency

528 1,086 0 456 51 463 0 1 166 1 275

Department Health Services

2)Report the percentage of the above numbers who received the respective service

3,597 8,031 1 2,958 597 3,031 222 2 995 7 1,972

a) Inpatient Chemical Dependency Services b) Intensive Outpatient or Partial

0.33% 0.31% 0.15% 0.27% 0.17% 0.27% 12.66% 0.00% 0.41% 0.00% 0.38%

Hospitalization Health Services c) Outpatient or Emergency

0.19% 0.17% 0.00% 0.18% 0.08% 0.18% 0.00% 0.36% 0.22% 0.07% 0.18%

Department Health Services 1.28% 1.28% 0.15% 1.17% 0.90% 1.17% 96.40% 0.72% 1.34% 0.47% 1.31%

40

Indemnity Managed Care Companies Mental Health Utilization - Follow-up After Hospitalization for Mental Illness


The percentage of discharges from a inpatient setting of an acute care facility, including acute psychiatric facilities, with a discharge date on or beween Jan 1 and Dec 1, 2012 for members 6 yrs of age or older who were hospitalized for treatment of select mental health disorders. a) who had an outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health practioner on the date of discharge up to 30 days after the hospital dis 81.01% 71.59% 100.00% 82.55% 86.00% 82.49% 83.33% 5.43% 84.36% 6.08% 84.95% charge. b) who had an outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health practioner on the date of discharge up to 7 days after the hospital discharge. 66.14% 56.74% 100.00% 67.45% 71.00% 67.51% 64.29% 1.81% 64.80% 2.47% 73.66%

Mental Health Utilization - Antidepressant Medication Management Aetna Anthem Celtic CIGNA ConnectiCare CT Golden John Oxford Time United Life BC-BS H & L General Rule Alden Health

The percentage of members 18 and older as of Apr. 30, 2012, who were continuously enrolled 90 days prior to the episode start date through 245 days after the start date, who were diagnosed with a new episode of depression between May 1, 2011 and Apr. 30, 2012, and treated with antidepressant medication, who met at least one of the following criteria during the intake period. * At least one principal diagnosis of major depression in an outpatient, ED, intensive outpatient or partial hospitalization; or * At least two visits in an outpatient, ED intensive outpatient or partial hospitalization setting on different dates of service with any diagnosis of major depression; or * At least one inpatient claim/encounter with any diagnosis of major depression. a) Who remained on antidepressant medication the entire 84 day period (12 week) acute treatment phase. 76.56% 71.10% 0.00% 74.41% 73.66% 74.00% 0.00% 0.00% 70.41% 0.00% 69.30% b) Who remained on antidepressant medication for at least 180 days (6 months). 62.31% 56.58% 0.00% 59.12% 53.66% 58.56% 0.00% 0.00% 57.40% 0.07% 54.08%

Aetna Life

Anthem BC-BS

Celtic CIGNA H & L


Golden Rule

John Alden

Oxford Health

Time United

For the period of Jan.1, 2012 through Dec. 31, 2012 Total number of claims recieved for the period

Provide the number of denials, of the total for each of the following:

1,689,259 2,073,450 2,391 527,410 1,355,043 613,891 188,365 3,683 2,244,627 17,236 4,634,889

1) not a covered benefit 63,812 11,445 5 3,876 7,502 4,671 12,932 84 22,024 356 253,036 2) not medically necessary

3) not an eligible 1,114 1,793 3 197 946 301 108 0 12,469 2 103,616

enrollee/dependent 109,316 74,077 1 342 20,446 423 5,185 0 65,651 3 9,155 4) incomplete submission 0 33,309 0 251 17,266 277 1,474 5 198,679 279 35,294 5) duplicate submission 0 61,208 3 416 48,749 503 11,351 239 118,684 860 226,810 6) all other miscellaneous

Provide denials as a percent of the total claims for the following reasons:

100,447 196,809 22 28,650 89,692 49,781 1,453 59 117,158 225 637,248

1) not a covered benefit 3.77% 0.55% 0.21% 0.69% 0.55% 0.76% 6.87% 2.28% 0.98% 2.07% 5.46% 2) not medically necessary

3) not an eligible 0.00% 0.09% 0.13% 0.04% 0.07% 0.05% 0.06% 0.00% 0.56% 0.01% 2.24%

enrollee/dependent 6.47% 3.60% 0.04% 0.06% 1.51% 0.07% 2.75% 0.00% 2.92% 0.02% 0.20% 4) incomplete submission 0.00% 1.60% 0.00% 0.05% 1.27% 0.05% 0.78% 0.14% 8.85% 1.61% 0.76% 5) duplicate submission 0.00% 2.95% 0.13% 0.07% 3.60% 0.08% 6.03% 6.49% 5.29% 4.99% 4.89% 6) all other miscellaneous 5.95% 9.50% 0.92% 5.11% 6.62% 8.11% 0.77% 1.60% 5.22% 1.31% 13.75%

41

Claim Expenses -Aetna Anthem Celtic CIGNA ConnectiCare CT Golden John Oxford Time United Life BC-BS H & L General Rule Alden Health

Provide the claim expenses on a per member per month basis for the period of Jan. 1, 2012 through Dec. 31, 2012, for each of the following.

Inpatient Mental Health $3.09 $2.56 $0.00 $3.34 $2.20 $2.25 $3.58 $0.07 $2.43 $1.38 $3.80 Inpatient Substance Abuse $0.28 $0.45 $2.44 $0.75 $0.70 $0.42 $0.75 $0.09 $0.54 $1.11 $2.34 Outpatient Mental Health $4.61 $8.55 $0.00 $5.12 $1.74 $4.70 $4.36 $0.94 $6.48 $15.66 $7.60 Outpatient Substance Abuse $2.18 $1.76 $0.01 $0.64 $1.21 $0.58 $1.04 $1.05 $0.91 $0.62 $1.25 Total of the above overall $10.16 $13.32 $2.45 $9.85 $5.85 $7.95 $9.73 $2.15 $10.36 $18.77 $14.99

Claim Denial Data

42

Member Satisfaction Survey – Health Maintenance Organizations

HMO Aetna Health Anthem BC-BS CIGNA ConnectiCare Oxford

Percentage of Managed Care members surveyed. 4.16% 1.00% 20.65% 0.77% 5.26% The percentage of those surveyed who responded. 23.99% 26.28% 19.25% 27.00% 33.03%

Q. In the last 12 months, how often did you get an appointment with a specialist as soon as you needed? Never 0.70% 2.78% 4.80% 2.00% 3.79% Sometimes 10.60% 6.67% 7.50% 14.00% 11.04% Usually 36.60% 25.00% 35.80% 36.00% 32.49% Always 52.10% 65.56% 51.90% 48.00% 52.68%

Q. In the last 12 months, not counting the times you needed care right away, how often did you get an appointment for your health care at a doctor's office or clinic as soon as you thought was needed? Never 1.60% 1.66% 1.30% 1.00% 2.06% Sometimes 15.90% 9.13% 13.00% 16.00% 12.61% Usually 31.20% 18.67% 29.70% 35.00% 27.52% Always 51.30% 70.54% 56.10% 48.00% 57.80%

Q. In the last 12 months, when you needed care right away for an illness or injury, how often did you get care as soon as you thought needed? Never 1.10% 1.71% 1.60% 4.00% 1.44% Sometimes 11.40% 4.27% 7.20% 7.00% 7.21% Usually 14.80% 17.09% 31.30% 27.00% 20.20% Always 72.70% 76.92% 60.00% 63.00% 71.15%

Q. In the last 12 months, how often was it easy to get care, tests or treatment, you thought you needed through your health plan? Never 1.00% 1.72% 1.60% 2.00% 0.47% Sometimes 9.20% 3.86% 9.40% 9.00% 6.12% Usually 27.60% 25.32% 31.40% 36.00% 24.94% Always 62.20% 69.10% 57.60% 53.00% 68.47%

Q. In the last 12 months, how often did the written materials or Internet provide the information you needed about how your health plan works? Never 1.50% 4.17% 8.70% 5.00% 4.30% Sometimes 25.40% 27.78% 30.10% 37.00% 36.56% Usually 50.70% 48.61% 42.70% 39.00% 44.09% Always 22.40% 19.44% 18.50% 19.00% 15.05%

Totals may not add to 100% due to rounding, or failure of some respondents to answer all questions.

43

HMO Aetna Health Anthem BC-BS CIGNA ConnectiCare Oxford

Q. In the last 12 months, how often did your health plan's customer service give you the information or help you needed? Never 2.90% 0.00% 1.70% 0.00% 2.40% Sometimes 24.30% 11.11% 26.90% 12.00% 14.40% Usually 31.40% 22.22% 24.40% 27.00% 25.60% Always 41.40% 66.67% 47.10% 61.00% 57.60% Q. In the last 12 months, how often were you satisfied with your prescription drug coverage? Never 5.10% 0.00% 0.40% 8.00% 1.86% Sometimes 18.20% 6.20% 15.20% 14.00% 6.00% Usually 29.10% 23.50% 48.20% 45.00% 38.10% Always 47.60% 70.30% 36.20% 33.00% 54.04%

Q. If you weren’t satisfied with your prescription drug coverage as stated in the above question, which one of these items would most closely identify your greatest area of concern? Copayments too high / percentage paid too low 28.60% 44.50% 53.20% 42.00% 42.08% Deductible too high 21.40% 11.10% 4.30% 23.00% 10.41% Maximum benefit too low 7.10% 0.00% 2.10% 5.00% 3.62% Cost of the benefit coverage too high 7.10% 0.00% 8.50% 2.00% 5.43% Managed care guidelines too restrictive (i.e. prior authorization) 14.30% 11.10% 13.50% 5.00% 14.93% Drug not included on the formulary 21.40% 33.30% 18.40% 13.00% 23.53%

Q. Use any number from 0 to 10 where 0 is the worst health plan possible and 10 is the best health plan possible. How would you rate your health plan now? (worst possible) 0 0.00% 0.40% 0.40% 1.00% 0.41%

1 0.50% 0.00% 0.40% 2.00% 0.62% 2 1.40% 0.79% 0.00% 3.00% 0.41% 3 4.10% 0.40% 0.70% 2.00% 1.24% 4 3.20% 1.98% 1.10% 3.00% 1.86% 5 16.70% 4.37% 7.10% 8.00% 5.77% 6 9.90% 5.56% 9.60% 9.00% 4.74% 7 15.30% 12.70% 11.80% 18.00% 11.55% 8 22.50% 19.05% 34.60% 25.00% 23.51% 9 13.10% 26.98% 18.60% 13.00% 22.47%

(best possible) 10 13.50% 27.78% 15.70% 18.00% 27.42%

44

Member Satisfaction Survey – Indemnity Managed Care Organizations

Carrier Aetna Life Anthem BC-BS Celtic CIGNA H & L ConnectiCare

Percentage of Managed Care members surveyed. The percentage of those surveyed who responded.

1.46% 24.56%

0.55% 25.76%

72.00% 11.00%

0.84% 20.68%

1.07% 34.00%

Q. In the last 12 months, how often did you get an appointment with a specialist as soon as you needed.

Never Sometimes Usually Always

1.20% 7.20%

29.50% 62.00%

1.27% 5.73%

35.67% 57.32%

43.00% 9.00%

20.00% 28.00%

4.00% 7.50%

34.80% 53.70%

2.00% 9.00%

38.00% 52.00%

Q. In the last 12 months, not counting the times you needed care right away, how often did you get an appointment for your health care at a doctor's office or clinic as soon as you thought was needed?


2.60% 11.80% 27.10% 58.50%

1.89% 8.49%

25.00% 64.62%

24.00% 15.00% 23.00% 38.00%

0.40% 11.50% 28.90% 59.30%

1.00% 13.00% 34.00% 53.00%

Q. In the last 12 months, when you needed care right away for an illness or injury, how often did you get care as soon as you thought needed?


0.00% 2.90%

20.20% 76.90%

1.08% 6.45%

20.43% 72.04%

30.00% 12.00% 24.00% 34.00%

0.80% 5.50%

22.00% 71.70%

0.00% 13.00% 27.00% 60.00%

Q In the last 12 months, how often was it easy to get care, tests or treatment, you thought you needed through your health plan?


0.90% 6.60%

23.80% 68.70%

0.00% 2.80%

31.78% 65.42%

30.00% 10.00% 30.00% 30.00%

1.50% 4.90%

31.20% 62.40%

2.00% 9.00%

34.00% 55.00%

Q. In the last 12 months, how often did the written materials or Internet provide the information you needed about how your health plan works?


2.80% 26.90% 47.20% 23.10%

5.97% 26.87% 46.27% 20.90%

24.00% 43.00% 15.00% 18.00%

5.20% 29.30% 50.90% 14.70%

6.00% 29.00% 44.00% 21.00%

45

CT General Golden Rule John Alden Oxford Health Time United

1.61% 19.96%

5.10% 25.30%

22.00% 11.00%

3.71% 23.12%

60.49% 13.00%

1.32% 27.60%

4.40% 7.50%

35.30% 52.80%

26.80% 13.00% 26.80% 33.40%

33.33% 16.67% 50.00%

0.00%

2.21% 11.50% 27.88% 58.41%

28.25% 14.25% 30.25% 27.25%

3.24% 13.77% 30.36% 52.63%

0.90% 12.30% 29.30% 57.70%

14.30% 18.10% 26.90% 40.70%

33.33% 16.67% 50.00%

0.00%

0.36% 13.50% 29.93% 56.20%

14.15% 14.15% 27.36% 44.34%

1.85% 14.20% 29.94% 54.01%

1.20% 7.70%

22.10% 69.10%

15.40% 7.00%

25.10% 52.50%

33.33% 16.67% 50.00%

0.00%

0.98% 8.82%

26.47% 63.73%

21.51% 9.68%

24.73% 44.08%

2.13% 9.93%

20.57% 67.38%

1.60% 7.20%

31.30% 60.00%

14.50% 9.80%

31.90% 43.80%

33.33% 16.67% 50.00%

0.00%

0.00% 11.59% 25.72% 62.68%

16.83% 15.84% 29.70% 37.63%

2.11% 7.25%

29.61% 61.03%

7.00% 29.70% 46.80% 16.60%

34.10% 18.40% 26.30% 21.20%

16.67% 50.00% 16.67% 16.67%

3.23% 39.78% 37.63% 19.35%

26.80% 27.84% 29.90% 15.46%

4.82% 30.12% 46.39% 18.67%

46

Member Satisfaction Survey – Indemnity Managed Care Organizations

Carrier Aetna Life Amer. Republic Anthem BC-BS Celtic ConnectiCare

Q. In the last 12 months, how often did your health plan's customer service give you the information or help you needed?

Never 6.80% 3.33% 28.00% 5.00% 2.00% Sometimes 1.40% 8.33% 21.00% 24.00% 18.00% Usually 21.60% 31.67% 24.00% 27.00% 34.00% Always 60.20% 56.67% 27.00% 44.00% 46.00%

Q. In the last 12 months, how often were you satisfied with your prescription drug coverage? Never 9.10% 1.30% 33.00% 2.10% 6.00% Sometimes 17.80% 7.10% 21.00% 16.40% 16.00% Usually 28.40% 28.30% 24.00% 46.60% 42.00% Always 44.70% 63.30% 22.00% 34.90% 36.00%

Q. If you weren't satisfied with your prescription drug coverage as stated in the above question, which one of these items would most closely identify your greatest area of concern? Copayments too high / percentage paid too low 14.30% 48.00% 43.00% 40.40% 43.00% Deductible too high 28.60% 12.00% 38.00% 19.20% 17.00% Maximum benefit too low 4.80% 8.00% 0.00% 6.00% 2.00% Cost of the benefit coverage too high 9.50% 12.00% 10.00% 14.60% 9.00% Managed care guidelines too restrictive (i.e. prior authorization) 19.00% 8.00% 0.00% 9.30% 9.00% Drug not included on the formulary 23.80% 12.00% 9.00% 10.60% 21.00%

Q. Use any number from 0 to 10 where 0 is the worst health plan possible and 10 is the best health plan possible. How would you rate your health plan now?

(worst possible) 0 0.70% 0.43% 3.00% 1.40% 1.00% 1 1.10% 0.43% 6.00% 0.00% 2.00% 2 1.50% 0.00% 9.00% 0.70% 2.00% 3 1.50% 2.55% 16.00% 2.00% 3.00% 4 1.90% 0.85% 10.00% 3.10% 3.00% 5 8.50% 7.66% 13.00% 9.20% 17.00% 6 7.80% 6.38% 6.00% 9.80% 7.00% 7 20.70% 11.91% 19.00% 15.90% 10.00% 8 24.40% 27.66% 9.00% 24.40% 26.00% 9 15.90% 17.45% 3.00% 19.30% 19.00%

(best possible) 10 15.90% 24.68% 6.00% 14.20% 11.00%

47

CT General Golden Rule John Alden Oxford Health Time United

3.40% 30.90% 0.00% 2.25% 19.42% 6.19% 25.50% 13.20% 60.00% 16.85% 18.45% 21.24% 25.70% 23.20% 20.00% 35.96% 24.27% 35.40% 45.60% 32.70% 20.00% 44.94% 37.86% 37.17%

1.30% 30.30% 0.00% 2.94% 24.00% 3.85% 15.80% 21.60% 40.00% 17.97% 24.00% 17.31% 47.40% 23.60% 60.00% 48.04% 21.00% 49.18% 35.60% 24.50% 0.00% 31.05% 31.00% 29.67%

46.80% 24.10% 66.66% 38.38% 36.84% 48.28% 11.80% 26.20% 0.00% 21.62% 29.82% 14.66%

4.10% 4.70% 0.00% 3.78% 3.51% 3.45% 11.60% 20.90% 33.34% 5.41% 12.28% 6.90% 11.40% 5.80% 0.00% 12.97% 7.02% 8.19% 14.50% 18.30% 0.00% 17.84% 10.53% 18.53%

0.90% 7.10% 0.00% 1.29% 4.63% 1.09% 0.20% 3.30% 16.66% 1.94% 3.70% 0.82% 0.40% 3.70% 0.00% 1.62% 4.63% 0.55% 1.40% 6.70% 0.00% 2.27% 7.41% 2.73% 2.10% 5.80% 16.66% 3.56% 4.63% 2.73% 8.20% 16.30% 16.67% 11.65% 15.74% 9.56% 9.70% 9.20% 16.67% 11.33% 8.33% 9.56%

13.90% 11.30% 16.67% 12.94% 18.52% 20.77% 29.50% 19.20% 0.00% 22.98% 16.67% 24.32% 19.00% 7.80% 0.00% 16.83% 11.11% 17.76% 15.00% 9.60% 16.67% 13.59% 4.63% 10.11%

48

2011 Medical Loss Ratio By Carrier

Carrier Name Type of MCO

2012 State Medical Loss

Ratio

Indivdual 2012 Federal Medical Loss

Ratio

Small Group 2012 Federal Medical Loss

Ratio

Large Group 2012 Federal Medical Loss

Ratio Aetna Health, Inc. of CT HMO 86.20% 107.20% 88.70% 89.50% Aetna Life Insurance Company Indemnity 78.50% 78.70% 63.70% 79.50% Anthem Blue Cross & Blue Shield of CT, Inc. HMO 82.80% 88.90% 85.70% 90.00% Anthem Blue Cross & Blue Shield of CT, Inc. Indemnity 83.70% 88.90% 85.70% 90.00% Celtic Insurance Company Indemnity 76.00% 76.00% 0.00% 0.00% CIGNA Health & Life Insurance Company, Inc. Indemnity 88.93% -16.60% 78.70% 94.30% CIGNA HealthCare of CT., Inc. HMO 1.10% 107.20% 93.00% 124.40% ConnectiCare Insurance Co. Inc. Indemnity 80.10% 80.90% 77.50% 88.80% ConnectiCare, Inc. HMO 83.20% 97.60% 82.70% 87.10% Connecticut General Life Insurance Company Indemnity 93.18% 112.40% 83.30% 88.40% Golden Rule Insurance Company Indemnity 78.20% 82.00% 0.00% 0.00% John Alden Life Insurance Company Indemnity 80.91% 77.80% 78.40% 74.10% Oxford Health Insurance, Inc. Indemnity 79.30% 89.00% 81.00% 85.00% Oxford Health Plans (CT), Inc. HMO 76.90% 94.00% 84.00% 81.00% Time Insurance Company Indemnity 57.96% 75.10% 84.70% 62.50% UnitedHealthCare Insurance Company Indemnity 75.92% 92.70% -267.60% 89.90%

49

Glossary Adverse determination: Any prospective review, concurrent review or retrospective review determination that denies, reduces or terminates or fails to provide or make payment, in whole or in part, for a benefit under the health carrier's health benefit plan requested by a covered person or a covered person's treating health care professional. "Adverse determination" includes a rescission of coverage determination for grievance purposes.

Board certified physician: A physician who has passed an examination given by a medical board for a particular specialty.

Capitation: A provider payment method in which a MCO pays a fixed amount per month for each enrollee regardless of the number of services performed.

Case management: A process whereby enrollees with specific health needs are identified by the MCO and a plan of treatment is set up and monitored to achieve optimum patient outcome in a cost effective manner.

Center for Medicare & Medicaid Services (CMS): The federal agency responsible for administering the Medicare program, including Medicare risk contracts with HMOs, and overseeing each state’s administration of the Medicaid program.

Coinsurance: A fixed percentage of the eligible medical expenses the enrollee is required to pay, in excess of any deductible.

Copayment: A flat fee that an enrollee is required to pay each time a specified service is rendered, in excess of any deductible.

Credentialing: A process of review to include and maintain a provider as a participating provider in the MCO’s network.

Deductible: The portion of eligible medical expenses in a calendar or contract year that an enrollee must pay before any benefits are paid.

Drug formulary: A listing of prescription drugs that are preferred for use by the MCO. The physician is encouraged to prescribe formulary drugs unless there is a valid medical reason to use a nonformulary drug. There may be higher cost sharing for nonformulary drugs.

Emergency medical treatment: Treatment for a condition a prudent layperson reasonably believes requires immediate medical attention. Coverage is determined based on either the presenting symptoms or the final diagnosis, whichever reasonably indicates an emergency medical condition.

Employee Retirement Income Security Act of 1974 (ERISA): Federal law that sets regulatory standards for employer plans.

Fee for service: A provider payment method in which a MCO pays a fee for each service provided.

Fully insured plan: A plan that is backed by an insurance policy that provides benefits for a premium.

50

Gatekeeper plan: A plan that requires an enrollee to first seek treatment from a chosen primar y care physician before seeing a specialist. The primar y care physician must make referrals to specialists for the services to be covered under the plan.

Health maintenance organization (HMO): A company that provides, offers or arranges for coverage of health services needed by plan members for a fixed, prepaid premium. In Connecticut, such organizations are licensed as health care centers.

Indemnity MCO: A licensed non-HMO insurer that offers a managed care plan in Connecticut.

Indemnity plan: An insurance plan in which the enrollee is reimbursed at a specified level for covered expenses.

Individual practice association (IPA): An association of physicians that contracts with a MCO to provide health services.

Managed care: A system of health care delivery that attempts to manage the access, cost and quality of health care by monitoring how and in what manner services are provided.

Managed care organization (MCO): An insurer, health care center, hospital or other organization delivering a managed care plan.

Managed care plan: An insured health plan that uses UR and a network of participating providers.

Mandated benefit: Policy benefits that are required to be provided by statute.

Medical loss ratio: The ratio of incurred claims to earned premium, which represents the percent of the premium that is applied to medical expenses.

NCQA accreditation: National Committee on Quality Assurance is a not for profit organization that reviews quality and performance measures of HMOs and health plans thereby providing an external standard of accountability.

Network plan: A plan that requires an enrollee to seek care from a provider who is under contract with the MCO to receive the highest level of benefits. This would also include a plan that provides additional coverage for services by providers outside the network. The out of network option generally provides coverage at a lower level of benefits.

Participating provider: A provider who has a contract with the MCO to deliver medical services to enrollees for an agreed upon fee.

Point of service plan (POS): A network plan that allows an enrollee to seek treatment from a non-participating provider at a lower level of benefits.

Preferred provider organization (PPO): An independent network of providers that contracts with a MCO to provide health services. A PPO cannot market insured health insurance policies on its own unless it obtains a license as an insurer or health care center.

Preferred provider organization plan: A network plan that allows an enrollee to seek treatment from a non-participating provider at a lower level of benefits.

51

Primary care physician (PCP): A physician chosen by an enrollee to provide primary care. The plan may require the PCP to make referrals to specialists for the services to be covered under the plan.

Preauthorization: The process whereby the MCO requires services or plans of treatment to be approved before given.

Precertification: The process whereby the MCO requires services or plans of treatment to be approved before given.

Prior authorization: The process whereby the MCO requires services or plans of treatment to be approved before given.

Provider: A physician, hospital, nursing home, pharmacy, lab or any individual or group that provides a health care service.

Reasonable and customar y fee: The commonly charged or prevailing fees for health services in a specific geographic area. Indemnity plans generally provide coverage for services based on the reasonable and customary fees. In addition to any deductible or coinsurance amount, an enrollee would be responsible for paying the provider the difference between the billed charge and the reasonable and customary charge if the billed charge was higher.

Referral: The request to the MCO by a primary care physician for an enrollee to receive care from a specialist, a non-participating provider or facility.

Self insured plan: A group plan in which the employer takes on the risk of claims. The employer will generally contract with a third party, often an insurance company, to handle the administration of the plan. Such plans are not regulated by the Insurance Department, but are subject to federal ERISA guidelines.

Utilization review (UR): The use of a set of formal techniques designed to monitor the use of, or evaluate the medical necessity, appropriateness, efficacy or efficiency of, health care services, health care procedures or health care settings. Such techniques may include the monitoring of or evaluation of (A) health care services performed or provided in an outpatient setting, (B) the formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility, (C) opportunities or requirements to obtain a clinical evaluation by a health care professional other than the one originally making a recommendation for a proposed health care service, (D) coordinated sets of activities conducted for individual patient management of serious, complicated, protracted or other health conditions, or (E) prospective review, concurrent review, retrospective review or certification.

Utilization review company (URC): A company, organization or other entity licensed in Connecticut to perform UR. Agencies of the federal and state government are not considered URC under Connecticut General Statutes.

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Additional licensed companies that offer a managed care plan in Connecticut but were not included in this guide. The same information found in this guide, is available directly from the companies or at the offices of the Insurance Department.

American Republic Insurance Company 601 Sixth Avenue Des Moines, IA 50334 1-800-247-2190

Guardian Life Insurance Company of America 7 Hanover Square New York, NY 10004 1-800-873-4542

Trustmark Insurance Company 400 Field Drive Lake Forest, IL 60045 1-800-366-6663

Trustmark Life Insurance Company 400 Field Drive Lake Forest, IL 60045 1-800-366-6663

Union Security Insurance Company 501 West Michigan Street Milwaukee, WI 53201-3050 1-800-800-1212

Note: Some companies may be servicing existing business and not currently issuing new business.

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Where to Find Help Or Additional Information AGENCY

Insurance Department Consumer Affairs Division

TYPE OF COMPLAINT OR INQUIRY

Insurance policies, companies, producers and

external appeals

ADDRESS

Mail Address: P.O. Box 816

Hartford, CT 06142-0816

TELEPHONE NUMBER(S)

(800) 203-3447 (toll free) (860) 297-3900

WEBSITE

http://www.ct.gov/cid

Office of the Managed care problems P.O. Box 1543 (866) HMO-4446 (toll free) http://www.ct.gov/oha Healthcare Advocate or questions Hartford, CT 06144

Department of Public Health Providers & Medical Facilities 410 Capitol Avenue Hartford, CT 06134

(800) 842-0038 (toll free) http://www.ct.gov/dph

U.S. Department of Labor Employer self funded or Pension & Welfare Benefits (617) 565-9600 http://www.dol.gov self insured health plans Bowdoin Square, 7th floor

Boston, MA 02114

National Committee for Quality Measures (800) 839-6487 (toll free) http://www.ncqa.org Quality Assurance (NCQA) (888) 275-7585 (toll free)

Health Reinsurance Association of CT (HRA)

Guaranteed Individual health coverage for residents under 65 Low-income Small

628 Hebron Avenue Suite 212

Glastonbury, CT 06033

(800) 842-0004 (toll free) http://www.hract.org

Employer Health Plans

Connecticuts Clearinghouse A single source for (877) 263-1997 http://www.cthealthchannel.org CT public & private

health insurance information

Department of Social Services Charter Oak Plan 25 Sigourney Street (800) 842-1508 (toll free) http:www.ct.gov/dss HUSKY Healthcare Hartford, CT 06106-5033

Temporar y High Risk Pool

U.S Department of Information on Healthcare http:www.healthcare.gov Health & Human Services Reform & Insurance Options

Access Health CT Online source for 280 Trumbull Street, 15th Floor 855-805-HEALTH http://www.accesshealthct.com (CT Insurance Exchange) Health Insurance Hartford, CT 06103

STATE OF CONNECTICUT INSURANCE DEPARTMENT

www.ct.gov/cid 1-800-203-3447

www.ct.gov/cid

2013 consumer report card on health insurance carriers in connecticut

Documents